Professional Documents
Culture Documents
* magloria@ufba.br
OPEN ACCESS
Conclusions
Physicians attending patients with dengue fever should keep those with hypertension or
skin allergies in health units to monitor progression for early intervention. This would reduce
mortality by dengue.
Author Summary
Dengue is a virus disease that has already reached more than 100 countries worldwide,
transmitted by Aedes mosquitos, mainly Aedes aegypti. It is estimated that annually nearly
96 million symptomatic cases and about 22,000 deaths occur. This virus most often mani-
fests itself in the form of Dengue Fever (DF), which in some cases progresses to severe
forms, also called Dengue Hemorrhagic Fever (DHF). However, the current knowledge
does not allow early prediction of which cases of DF will progress to DHF. But it is impor-
tant to know the factors Involved in this process so that physicians may intervene early to
prevent progression and avoid deaths. One of the proposed explanations is that preexisting
comorbidities would increase the risk of progression from DF to DHF. This study showed
that cases of DF associated with hypertension or skin allergy are more likely to progress to
DHF. Monitoring and early appropriate clinical management of these cases can save lives.
Introduction
The reemergence of dengue—which is now present in over 100 countries—is a global public
health problem [1]. It is estimated that there are 390 million dengue infections every year
worldwide, of which 96 million are symptomatic and about 22,000 fatal [2].
Dengue Fever (DF) is a mild disease; progression to dengue hemorrhagic fever/dengue
shock syndrome (DHF / DSS) is relatively rare, but the case fatality rate of cases that do prog-
ress is high. Currently knowledge does not allow early prediction of which cases of dengue
fever (DF) will progress to dengue hemorrhagic fever (DHF), to allow early intervention to pre-
vent progression or to limit severity [3]. There is evidence a second heterologous dengue virus
(DENV) infection is more likely to progress to severe dengue [4]. Halstead (1980) [4] proposed
that the mechanism underlying DHF/DSS is antibody-dependent enhancement (ADE) of den-
gue virus infection. ADE seems to acts as an idiosyncratic Fc-receptor signalling [5] which in
its turn would modulate the disease severity through suppressing the innate immune system
(macrophages/monocytes), abrogating immune response to virus throughout inhibition of in-
terferon transcription factors, STAT1, and NFκB complexes, decreasing nitric oxide produc-
tion, and increasing interleukin 10 [6]. This would increase the numbers of infected cells, viral
production per cell and cytokine production leading to vascular permeability, coagulopathy
and ultimately the capillary leakage characteristic of DHF [5].
In some endemic areas, over 70% the population has antibodies to dengue virus, but the cu-
mulative incidence of DHF is under 1% [7]. Clearly, other factors must contribute to the devel-
opment of severe dengue. It is likely that the host genetic background and viral strains and
serotype influence the risk of this progression. One of the proposed explanations was that pre-
existing comorbidities would increase the likelihood of progression from DF to DHF. The hy-
pothesis was generated in an uncontrolled case series [8,9] and explored in two case control
studies (one by our group here in Brazil and one in Singapore). Both were conducted retrospec-
tively and both found that cases of DF were less likely than cases of DHF to report previous
diabetes mellitus and allergies [10] and diabetes with hypertension [11]. We therefore decided
to conduct an concurrent case control study, with recruitment of incident (rather than past)
cases, for monitoring the clinical course, and collection of information as cases are diagnosed
to reduce vulnerability to information bias and provide a rigorous confirmation of these
initial findings.
Methods
The objective of the study was to investigate whether specific morbidity due to chronic illnesses
increased the risk of progression from DF to DHF/DSS. The study was conducted in Brazil, the
country with the highest number of DF cases in the world [12]. The study area included 6 cities:
Campo Grande/MS, Fortaleza/CE, Itabuna/BA, Jequié/BA (2009), Ilhéus/BA and Salvador/BA,
This was an unmatched concurrent case-control study, with cases and controls recruited in
the Infectious Diseases Reference Hospitals in each of the 6 cities during epidemic years, from
2009 to 2012. In 2009, the DENV2 predominated (in the epidemics of Jequié, Ilheus and Ita-
buna). In 2010 (in Campo Grande) and 2011 (in Salvador) DENV1 predominated. In 2012, the
predominant serotype was DENV4 (in Salvador and Fortaleza). From 2009 to 2011 had simul-
taneous circulation of three serotypes (DENV2, DENV3 and DENV1). From 2011, all four se-
rotypes circulated simultaneously.
Recruitment: patients admitted in the hospitals with signs and symptoms of dengue were in-
vited to participate in the study. During the first contact an interview was conducted, and cases
of DF were accompanied by the research team physician until a final diagnosis, and those who
progressed to DHF/DSS) were classified as cases and those who did not progress for DHF were
classified as controls.
Case definition: Patients with dengue fever who progressed to DHF according to the WHO
1997 criteria [13]: fever, hemorrhagic manifestations, thrombocytopenia (<100×109/L) and
evidence of plasma leakage (hematocrit change 20%, hypoproteinemia or clinical fluid accu-
mulation), and one positive specific laboratory diagnosis for dengue.
Control definition: Patients, from the same hospital as cases, with signs and symptoms of
DF (fever, headache or retroorbital pain, myalgia, arthralgia, prostration, exanthema and posi-
tive specific laboratory diagnosis for dengue [13] who did not progress to DHF.
Laboratory investigation: Platelia dengue NS1 Ag kit (Bio-Rad laboratories Marnes-le-
Coquette France and/or DENV IgM Capture by ELISA Kit PanBio Queensland, Australia).
Prior serologic status (IgG) of the cases and control was not investigated, so past history of
Dengue was not established.
Data collection: Patients (and/or relatives) were interviewed when they arrived in the hospi-
tal, by trained interviewers, using a previously tested, standardized questionnaire to obtain
demographic and biological data (name, address, age, sex self-reported skin color), socioeco-
nomic indicators (years of schooling and family income). Clinical information included signs
and symptoms of dengue, reported other health conditions (diabetes, hypertension, allergy,
asthma) and use of medication for control of these illnesses. When the individual reported one
of the conditions of interest, he/she was asked who made the diagnosis and the interviewer
asked to see the prescription and/or packaging of any medication. Only subjects able to show
packaging or prescriptions were considered to have the condition. As skin allergies have a wide
spectrum, subjects were considered to have "allergy" if they reported allergy and provided evi-
dence of having used anti-allergic medication, including a prescription.
Statistical analysis: Associations between each co-morbidity and DHF was investigated
using the χ2 test (Fischer's exact test when appropriate). Stratified analyses were conducted to
assess confounding; age ( 15 and <15 years) was investigated as an effect modifier. Logistic
regression models were defined to estimate the independent association between DHF and
hypertension, diabetes, allergy and asthma. STATA software, version 12 was used for the
analyses.
Sample size: the necessary sample size to detect an odds ratio (OR) of 1.7 for the progression
from DF to DHF, for a frequency of co-morbibity of 9.1% (for prevalence of asthma, the least
common of the co-morbidities studied), with 95% precision, 80% power, with a ratio of 4 con-
trols per case, was estimated to be 303 cases and 1212 controls,
Ethical approval was obtained from the Research Ethics Committee, Instituto de Saúde
Coletiva, Federal University of Bahia, Salvador, Brazil (No. 013/03/CEP-ISC). Cases and con-
trols gave written informed consent.
Results
The study included 490 cases of DHF and 1,316 controls with DF. 64.5% of the cases were over
15 years of age. Nearly 60% of adult cases were female, 55% considered themselves mixed race,
about 48% had income 1 minimum monthly salary (USD 239–306), 56.7% had at least ten
years of schooling. Of the controls, 69.3% were over 15 years of age, 63.5% were female, 44%
considered themselves mixed race, and 40.4% had a family income between 2–3 minimum sal-
aries and 53% had 10 years or more of schooling. Cases and controls aged less than 15 years
were similar in distribution, with approximately 52% female, 70% with a family income 1
minimum monthly salary; 65% of cases and 60% controls declared themselves to be mixed race
(Table 1).
Self-reported skin color, family income and skin allergy showed a statistically significant as-
sociation with DHF (p<0.05) among subjects aged over 15 years (Table 2). Crude association
with DHF were found with family income and also when adjusted for skin color, sex and age,
for income between 2–3 minimum salaries (OR = 0.6, 95% CI 0.4–0.8); income for > 3 mini-
mum salaries (OR = 0.5 95% CI 0.3–0.8). When each self-reported chronic disease was adjusted
for ethnic and social variables, only hypertension (OR = 1.6; 95% CI 1.1–2.1) and skin allergy
(OR = 1.8; 95% CI 1.1–3.2) were associated with DHF (Table 3). Association were statistically
significant between DHF and self-reported skin allergies (only when medication was not used
at the time of the illness, OR = 2.1, 95% CI 1.1–4.1), and with hypertension both when the sub-
jects were using of antihypertensive drugs (OR = 1.4; 95% CI 1.1–2.0) and when they were not
using antihypertensive drugs (OR = 1.8; 95% CI 1.1–3.2).
There was no statistically significant associations in those younger than 15 years.
Discussion
Adults with DF and preexisting arterial hypertension or skin allergy were, respectively, 1.6 and
1.8 times more likely to progress to DHF. With respect to hypertension, this risk was marginal-
ly stronger in individuals who were not receiving treatment. This association was observed pre-
viously in Brazil in black individuals [10], while in Singapore hypertension was a risk factor for
developing DHF when associated with diabetes [11].
The mechanism by which arterial hypertension might increase the risk of progression to
DHF is not well understood, although the association is plausible. Hypertension leads to endo-
thelial dysfunction and vascular damage, promoting inflammatory activation of the endotheli-
um, changing the regulation of vascular tone and flow [14]. There is some evidence that
C-reactive protein (CRP) [15], commonly elevated in hypertension, can promote detrimental
effects on the vascular wall, inducing endothelial dysfunction and reducing nitric oxide bio-
availability, which also operates in tissue coagulation [16]. This could contribute to increased
vascular permeability and coagulopathy, loss of fluid that may progress to hypovolemic shock,
Table 1. Socioeconomic, demographic and comorbidity characteristics of patients with Hemorrhagic Dengue Fever (cases) and Dengue Fever
(controls) living in six municipalities of Brazil 2009–2012.
Characteristics Case N = 316 Controls N = 912 p value Case N = 174 Controls N = 404 p value
Sex
Female 188 (59,49) 579 (63,49) 91 (52,3) 210 (51,98) 0,94
Male 128 (40,51) 333 (36,51) 0,206 83 (47,7) 194 (48,02)
Age
7 - - 50 (28,74) 112 (27,72) 0,512
8–11 - - - 80 (45,97) 175 (43,31)
12–15 - - 44 (25,28) 117(28,96)
Skin color
Black 40 (12,7) 132 (14,67) 30 (17,54) 58 (14,5) 0,120
White 102 (32,38) 373 (41,4) 0,003 30 (17,54) 101 (25,25)
Mixed 173 (54,92) 395 (43,89) 111 (64,91) 241 (60,25)
Income
1 144 (47,84) 286 (33,53) 117 (70,48) 258 (70,88) 0,774
1–3 103 (34,22) 345 (40,45) 0,000 38 (22,89) 76 (20,88)
3 54 (17,94) 222 (26,03) 11(6,63) 30 (8,24)
Schooling
0–3 39 (13,31) 83 (10,35) - - -
3–7 39 (13,31) 143 (17,83) 0,146 - - -
7–10 49 (16,72) 151 (18,83) - - -
10 166 (56,66) 425 (52,99) - -
Hypertension
No 226 (71,52) 690 (75,82) 0,108 173 (99,4) 403 (99,7) 0,512
Yes 90 (28,48) 217 (23,85) 1 (0,6) 1 (0,25)
Allergy
No 251 (79,43) 164 (17,98) 0,309 123 (70,69) 304 (75,25) 0,250
Yes 65 (20,57) 748 (82,02) 51 (29,31) 100 (24,75)
Food Allergy
No 302 (95,57) 880 (96,60) 0,061 158 (90,80) 384 (95,05) 0,061
Yes 14 (4,43) 31 (3,40) 16 (9,2) 20 (4,95)
Respiratory Allergy
No 273 (86,39) 791 (86,83) 0,844 140 (80,46) 332 (82,38) 0,583
Yes 43 (13,61) 120 (13,17) 34 (19,54) 71 (17,62)
Skin Allergy
No 291 (92,09) 869 (95,49) 0,029 162 (93,64) 380 (94,06) 0,850
Yes 25 (7,91) 41 (4,51) 11 (6,36) 24 (5,94)
Diabetes
No 297 (94,59) 863 (94,84) 0,558 174 (100) 401 (99,26) 0,250
Yes 17 (5,41) 47(5,16) - 3 (0,74)
Asthma
No 306 (96,84) 891 (98,8) 0,161 161 (92,53) 383 (95,51) 0,161
Yes 10 (3,16) 20 (2,20) 13 (7,47) 18 (4,49)
a
—Salvador; Ilhéus; Itabuna; Jequié; Fortaleza; Campo Grande.
doi:10.1371/journal.pntd.0003812.t001
Table 2. Odds ratio crude and adjusted obtained by logistic regression for the association between Dengue Hemorrhagic Fever and socioeco-
nomics and demographic variables of residents in six municipalitiesa of Brazil, according to age group 2009–2012.
doi:10.1371/journal.pntd.0003812.t002
Table 3. Odds ratio crude* and adjusted obtained by logistic regression for the association between
Dengue Hemorrhagic Fever and select comorbidities of 15 years old residents in six municipalities
of Brazil 2009–2012.
doi:10.1371/journal.pntd.0003812.t003
allergies should keep the patients for observation to be able to intervene in a timely fashion and
avoid death. We recommend that research be conducted to understand the pathogenesis DF/
DHF/DSS, focusing on the influence of the immune system, especially the role of cytokines,
such as IL-10 on the evolution from DF to DHF. In particular, we recommend continuing to
investigate the influence of the immune system in order to possible the identification of immu-
nological biomarkers that can function as prognostic indicators of progression.
Supporting Information
S1 Checklist. STROBE checklist. Found at: doi:10.1371/journal.pntd.0000699.s001 (0.20 MB
RTF) http://www.strobe-statement.org/fileadmin/Strobe/uploads/checklists/STROBE_
checklist_v4_combined_PlosMedicine.pdf
(DOC)
Author Contributions
Conceived and designed the experiments: MGT MdCNC RVC MLB RB LCR. Analyzed the
data: MGT ESP MdCNC LCR. Contributed reagents/materials/analysis tools: ESP LP JPD CAF
MAAF VM. Wrote the paper: MGT ESP RVC MdCNC CAF MLB. Data collection: ESP JPD
MAAF VM RVC LP.
References
1. WHO. Dengue and severe dengue. Fact sheet N°117. 2014. Available: http://www.who.int/
mediacentre/factsheets/fs117/en/.
2. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and
burden of dengue. Nature. 2013; 496: 504–507. doi: 10.1038/nature12060 PMID: 23563266
3. WHO. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control; 2009. PMID: 23762963
4. Halstead SB. Dengue haemorrhagic fever. A public health problem and a field for research. Bull World
Helth Organ. 1980; 58: 1–21.
5. Halstead SB. Dengue. Lancet. 2007; 370(9599):1644–52. PMID: 17993365
6. Halstead SB, Mahalingam S, Morovich MA, Ubol S, Mosser DM. Intrinsic antibody-dependent enhance-
ment of microbial infection in macrophages: disease regulation by immune complexes. Lancet Infect
Dis. 2010; 10: 712–722. doi: 10.1016/S1473-3099(10)70166-3 PMID: 20883967
7. Murray NE, Quam MB, Wilder-Smith A. Epidemiology of dengue: past, present and future prospects.
Clinical Epidemiology. 2013; 5; 299–309. doi: 10.2147/CLEP.S34440 PMID: 23990732
8. Bravo JR, Guzmán MG,Kourí GP. Why dengue haemorhagic fever in Cuba? 1. Individual risk factors
for dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS). Trans R Soc Trop Med Hyg 1987;
81: 816–820. PMID: 3450004
9. Cunha RV, Schatzmayr HG, Miagostovich MP, Barbosa AMA, Paiva FG, Miranda RMO, et al. Dengue
epidemic in the State of Rio Grande do Norte, Brazil, 1997. Trans R Soc Trop Med Hyg 1999; 93: 247–
49. PMID: 10492750
10. Figueiredo MA, Rodrigues LC, Barreto ML, Lima JWO, Costa MCN, Morato V, et al. Allergies and Dia-
betes as Risk Factors for Dengue Hemorrhagic fever: Results of a Case Control Study. PLoS Negl.
Trop. Dis. 2010; 4: 699–705.
11. Pang J, Salim A, Lee VJ, Hibberd ML, Chia KS, Leo YS, et al. Diabetes with Hypertension as risk fac-
tors for adult dengue hemorrhagic fever in a predominantly dengue serotype 2 epidemic: a case control
study. PLoS Negl Trop Dis. 2012; 6(5):e1641. doi: 10.1371/journal.pntd.0001641 PMID: 22563519
12. Teixeira MG, Costa MC, Barreto F, Barreto ML. Dengue: twenty Five years since reemergence in Bra-
zil. Cad. Saúde Pública. 2009; 25. doi: 10.1590/S0102
13. WHO. Dengue hemorrhagic fever: Diagnosis, Treatment, Prevention and Control. Geneva; 1997.
14. Savoia C, Sada L, Zezza L, Pucci L, Lauri FM, Befani A, et al. Vascular Inflammation and Endothelial
Dysfunction in Experimental Hypertension. International Journal of Hypertension. 2011. doi: 10.4061/
2011/281240
15. Hage FG. C-reactive protein and Hypertension. J Hum Hypertens. 2014; 28(7):410–5. doi: 10.1038/
jhh.2013.111 PMID: 24226100
16. Pauletto P, Rattazzi M. Inflammation and hypertension: the search for a link. Nephrol Dial Transplant.
2006; 21: 850–853. doi: 10.1093/ndt/gfl01 PMID: 16464884
17. Guzman MG, Alvarez M, Halstead SB. Secondary infection as a risk factor for dengue hemorrhagic
fever/dengue shock syndrome: an historical perspective and role of antibody-dependent enhancement
of infection. Arch Virol. 2013; 158(7):1445–59. doi: 10.1007/s00705-013-1645-3 PMID: 23471635